Academic redlining in medicine

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Abstract

Despite concerted efforts over the past decade to increase diversity in U.S. medical schools, persistent applicant and enrollment gaps remain for students from underrepresented racial and economic backgrounds. To understand these gaps, we propose a new theory of ‘academic redlining’ as a widespread practice in medical schools that systematically excludes students from underrepresented backgrounds from entry into medicine through the nearly universal use of Medical College Admissions Test (MCAT) cutoff scores. In this paper, we provide evidence that academic redlining via the MCAT disenfranchises students from underrepresented backgrounds prior to and during the admissions process due to structural racism, and describe the three core mechanisms that cause medical schools to engage in academic redlining: (1) the pursuit of institutional prestige, (2) market competition and pressure, and (3) market bands. Given the persistent lack of diversity in medicine—which contributes to devastating health care disparities—as medical schools redouble their commitments to diversity, equity, and inclusion, structural alternatives within medical schools’ admissions and education practices are offered to curtail the practice of academic redlining in medical school admissions and medicine.

Introduction

Despite current efforts to improve diversity, medicine continues to experience a profound lack of diversity due to the striking absence of physicians from underrepresented racial and economic backgrounds.1,2 In 2018, despite African Americans and Latinas comprising 13% and 18% of the U.S. population, respectively, only 5% of physicians were African American and 6% were Latina.3,4 These low numbers have created severe disparities in physician access, quality medical care, and health status among patients from these underrepresented groups1,2,5 based on significant evidence that the presence of underrepresented health providers may decrease health disparities by improving patient outcomes, satisfaction, and communication.6,7,8

A major driver of this diversity crisis is the low, unequal medical school admissions rates of students from underrepresented backgrounds.9 The Flexner Report of 1910 led to the purposeful closure of schools that trained racial, ethnic, and gender minority groups.10,11 Since then, medical schools have struggled to enroll women, students from low-income families, and racial/ethnic minorities.11 While successful efforts to reduce the gender gap led women to surpass men in total medical school enrollment in 2019,12 similar efforts have failed to bridge the admissions gap for students from underrepresented racial and economic backgrounds.13,14 For example, the Association of American Medical Colleges ‘Project 3,000 by 2000’ campaign to increase medical school enrollment from underrepresented groups fell far short of its goal.15 Consequently, admissions rates for underrepresented students have remained persistently low, resisting local and national efforts to promote diversity in medical school admissions and enrollment.16

In this paper, we argue that the workforce diversity challenges facing medicine are the direct consequence of a significant but underrecognized structural problem in the medical school admissions process: the systematic exclusion of qualified applicants from underrepresented racial and economic backgrounds due to the use of the Medical College Admissions Test (MCAT).17 We name this exclusionary practice ‘academic redlining’ because of its stark parallels to the discriminatory ‘redlining’ practice that denied generations of minorities homeownership and wealth-building by labeling qualified minority homebuyers and neighborhoods unworthy of loans based on race.18

Redlining refers to corporate and government housing loan discrimination by federal agencies, lenders, and developers based on racially-biased assessments of minority neighborhoods as inherently undesirable and less valuable—an “unconstitutional and discriminatory racial policy.”18 This discriminatory labeling began in the 1930’s with the denial of home loans to qualified minority homebuyers, with banks using racism to manipulate the value of investments and assets at the expense of minority neighborhoods. Over time, redlining wrought numerous ill effects on minorities by (1) denying millions of residents from low-income, mostly African American neighborhoods homeownership; and (2) diminishing property values for existing African American homeowners. Following redlining, residential segregation increased and the chasm of household wealth rose dramatically; generating a profound U.S. racial wealth gap19 in which African American families now possess only 10 cents of wealth for every dollar possessed by White families.20

Section snippets

Academic Redlining

Due to its stark parallels to historical redlining, we define ‘academic redlining’ as the systematic exclusion in medical education of potentially qualified applicants from underrepresented racial and economic backgrounds due to admissions committees’ pervasive use of cutoff scores on the MCAT: a ‘standardized’ assessment designed to predict an applicant's potential for medical school failure/success. To illuminate this potential bias, we present and compare national test taker data and

Conceptualizing Academic Redlining in Medicine

In the following sections, we present our model outlining the mechanisms through which academic redlining operates to limit the compositional diversity of medicine. First, in our theory, we define academic redlining as occurring at a given medical institution only if the use of MCAT score cutoffs negatively impacts the institution's compositional diversity of students. Consequently, for the limited group of medical schools for which using MCAT score cutoffs does not affect the compositional

Discussion

The proposed academic redlining model indicates that schools impede their own diversity efforts by excluding underrepresented students based on the unsupported belief that students with lower MCAT scores possess lower potential for achievement and success in medicine. In distilling the potential of a qualified medical school applicant to their MCAT score—a tool with wide score gaps by race and socioeconomic status—academic redlining practices play a major structural role in harming the

Conclusion

Despite the growing trend of individualized holistic review in medical school admissions, academic redlining due to medicine's overreliance on MCAT cutoffs continues to drive many schools’ admissions practices17 due to the intense pressures upon schools to achieve/maintain institutional prestige and market position. By denying otherwise qualified underrepresented applicants entry into medicine based on their standardized test performance, academic redlining is profoundly impacting the

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    Conflict of Interest: The authors have no competing or conflicting interests to disclose.

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